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elLocation and deta._ of monitoring/leak detection systems <br /> 6. Location of underground utility lines and vaults <br /> 7. Site address, property lines, scale, ncrth arrow <br /> 8. Surface elevation and location of 100 year flood plain, if applicable <br /> 9. Equipment summary <br /> M. Required Inspections - New Tank Installations <br /> Each new tank installation must <br /> stages: be inspected by the E.N, at each of the following <br /> 1. installation of secondary containment ( liner) system, where applicable <br /> 2. delivery and test of tank on site; excavation complete; placement of tank in exca- <br /> vation <br /> 3. product line and associated piping - pressure test on <br /> protection devices installed lines and tank; overfill <br /> 4, monitoring system installed; monitcr ports brought to surface <br /> v <br /> N. I declare that to the best of my knowledge and belief the statements and information <br /> that provided <br /> above <br /> above may correct <br /> ne deand d Vie. I uunderstand that information in <br /> addition to <br /> Health Services (DHS) and that no workoiser to to b obtain a permit from the Department of <br /> issued, egin on this project until the permit is <br /> I understand that any changes <br /> inotdesign, materials or equipment will void my permit to <br /> construct if prior approval <br /> obtained. <br /> I understand that a permit to operate the underground storage tank system must be <br /> obtained from the Department within 60 days of putting the system into use. <br /> the responsibility of the tank owner. Conditions of the permit to operate include an <br /> acceptable tank monitorin This is <br /> and regular inspection by t hen testing schedule, submittal of an annual report form, <br /> I will notify the Department of Health Services at least two working days (48 hours ) <br /> in advance to schedule each required inspection. I understand that site and worker <br /> safety are solely the responsibility of the property owner or his agent and that this <br /> responsibility is not shared nor assumed by the County of San Diego. <br /> Signature & Title: <br /> Print Name <br /> Telephone ( ) <br /> Date <br /> _— ^n (1, ! 4) �S /�v�C <br /> Y` / j;J �.., off' . CC-. !c , <br /> Z7r�c�. f� e.� Qp�v„ II-3 <br /> C,4 ��,..-c.o �,.� / g S�i..+✓-i�c� Go•.,Lo-�......_...Z`c�-� G�cr<..-�..�n� <br /> r <br />